09/09/2013 // Justice News Flash: Featured Column (Press Release) // Kathleen Scanlan // (press release)
Healthcare has evolved in many ways. Advances in technology allow many patients to stay right in their own homes while getting life-saving treatment. To keep up with these advances, and because home health care is less expensive than treating people in acute care hospitals, government programs like Medicare provide home health care benefits.
The use of the Medicare home health benefit is widespread. To qualify a beneficiary must be under the care of a doctor and receiving services under an authorized “plan of care.” Patients must be in need of skilled nursing care, physical therapy, speech language pathology, occupational therapy, or medical social services. The care they receive is ongoing, but part-time.
Medicare spends billions of dollars on health care services for people who are confined to their homes suffering from anything from diabetes to heart failure. For example, in 2008, Medicare paid for roughly 118 million home care visits at a cost of $17 billion dollars. (Medicaid also provides home health care to indigent Americans who qualify.)
Home health care is supplied by more than 10,000 certified agencies across the United States. With thousands of certified providers billing the government for reimbursement of home healthcare services, it is perhaps not surprising to also find fraud. The fact that the majority of these providers are non-profits has, ironically, not deterred fraud. With the aging of the Baby Boomer generation upon us, the levels of home health care that will be provided – and the associated risk of even more fraud, are bound to increase. To choke off this new fraud industry, it’s important for all Americans to recognize the most common examples of home healthcare fraud, including:
• Falsifying home care workers’ timesheets
• Billing for services not rendered or not reimbursable
• Falsifying reports of inspections that never occurred
• Exaggerating a patient’s illness to “upcode,” or bill at a higher cost
• Charging for tests or procedures that were medically unnecessary
• A home care business paying kickbacks to a doctor for referrals
• Billing Medicare and Medicaid for the same services
• Using home care workers who are not properly certified
Anticipating this new growth industry, the federal government has cracked down on home health care chains and individual workers in recent years, filing False Claims Act lawsuits recouping tens of millions of dollars. For example, in 2011 – in one of the biggest cases involving home health care fraud in recent years, New Jersey-based Maxim Healthcare Services, Inc. agreed to pay $130 million in civil settlements and $20 million in criminal penalties related to a nationwide scheme to defraud Medicaid, Veterans Affairs, and other federal health care programs. One of the country’s largest home health care providers with hundreds of offices nationwide, Maxim was accused of billing for services that were not given or that were not properly documented, and for billing for services performed by 13 unlicensed offices. In 2009, two home health care workers in New York blew the whistle on their employers for fraudulently billing the government for the services of uncertified workers. They received a combined $2 million for their role in exposing the fraud.
The reality of home health care is that a whistleblower does not need to be an employee at one of these agencies to see that there is fraud happening. Everyone gets sick. Everyone grows old. This puts patients and caregivers in the unique position of monitoring exactly what is – and is not – being provided in terms of service. After all, the money each of us safeguards in combatting this fraud may be the money that funds our own care in years to come.
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